autism spectrum disorders centers of excellence · 10 request for information • november 2, 2016:...
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Autism Spectrum Disorders Centers of Excellence
July 19, 2017
Presenters
Karrie Steving serves as Children’s System of Care Administrator for Mercy Maricopa Integrated Care (Mercy Maricopa), the Regional Behavioral Health Authority in Maricopa County. Dr. Ramiro Guillen serves as Chief Medical Officer for Southwest Behavioral and Health Services. Dr. Bryan Davey serves as Chief Executive Officer (CEO) for Touchstone Health Services in Phoenix, Arizona. Lindsey Zieder serves as Children’s System of Care Special Projects Lead for Mercy Maricopa Integrated Care (Mercy Maricopa), the Regional Behavioral Health Authority in Maricopa County.
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Session Objectives
Objective 1: Participants will be able to outline the evidenced based practices used to treat and improve whole-health outcomes for members with Autism Spectrum Disorder.
Objective 2: Participants will be able to outline multi-systemic approaches for promoting coordination of care and consistency for youth/adults and families, while keeping the member and family at the center of the team.
Objective 3: Participants will be able to discuss mechanisms for engaging families, multi-system/inter-disciplinary service providers, including the Arizona Department of Education to provide integrated physical and behavioral health services.
Mercy Care Plan l Mercy Maricopa
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Identified Need
• Enhance the whole-health outcomes for the Autism Spectrum Disorder population within our community.
• Efficiency and effectiveness of managing the coordination of services
across systems, which include: - Diagnostic screening - Evidenced based practices - Collaborative with the Division of Developmental Disabilities, Primary Care and the Arizona Department of Education. • Promote stability and permanency for youth and families - Incorporating comprehensive assessments - Early childhood screening tools - Oversight of developmental milestones and functional limitations
Mercy Care Plan l Mercy Maricopa
National Data
• Autism Spectrum Disorder (ASD) is a biologically based neurodevelopmental disorder. It is defined as delayed social communication skills, social interactions, and restricted, repetitive behaviors (RRB).
• Prevalence 1 in 68 (CDC, 2014).
• Early Intervention can considerably improve long-term development and social behaviors.
• 5x ASD is almost five times more common among males versus females.
• Autism is one of the fastest growing developmental disorders in the United States.
American Psychiatric Association. Autism spectrum disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p. 50.
Christensen DL, Baio J, Van Naarden Braun K, et al. Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 years – Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012. MMWE Surveill Summ 2016; 65:1
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National Data
• About 1 in 6 Children have developmental disabilities.
• ASD is estimated to affect more than 3 million individuals in the United States.
• Variation linked to socio-economic status and culture.
• Approximately 50,000 individuals with autism spectrum disorder (ASD) turn 18 each year in the United States.
• Staggering rates on unemployment, lack of vocational training and/or college.
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National Data
CDC surveys (NHIS & NSCH)
Mercy Care Plan l Mercy Maricopa
National Practices – Core Components
As described by the Division of Adolescent and School Health of the Centers for Disease Control and Prevention, best practices for members with ASD include:
(1) Early intervention services: birth to 3 years of age
(2) Behavior and communication approaches
(3) Relationship-based approaches
(4) Dietary approaches
(5) Medication
(6) Complimentary and alternative medicine
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Response to the Community Need
Autism Spectrum Disorder
Center of Excellence
Medical and Behavioral Integration
Community Enrichment
Continuity of Care
Multi-system Involvement
Comprehensive Assessments
Evidence-based Practice
Key Elements
• Serve as the ‘hub’ • Drive holistic outcomes • Advanced coordination
of care • Educate the community • Specialized services • Family and member
advocacy
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Request for Information • November 2, 2016: Mercy Maricopa Integrated Care and Mercy Care Plan issued a Request
for Information (RFI) • December 16, 2016: 9 responses were received • Multi-disciplinary team came together to design the Autism Disorder Spectrum Centers of
Excellence Model, in collaboration with the Division of Developmental Disabilities (DDD) •
Collaborative Efforts
Children’s System of Care Physical Health Medical Director
Integration DDD Liaison
Cultural Competency Utilization Management
Adult System of Care DDD
DDD Liaison General Mental Health/Substance Abuse Representative
Office of Individual and Family Affairs Physical Health Manager
Integration Officer
Mercy Care Plan l Mercy Maricopa
Autism Spectrum Disorder Centers of Excellence
Touchstone Health Services
Southwest Behavioral Health Services
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Southwest Behavioral & Health Services
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Prevalence and early signs
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Features of Autism
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DSM Criteria for Autism
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Psychopathology associated with ASD in psychiatrically referred populations
J O S H I E T A L . , 2 0 1 0 , 2 0 1 3
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Anxiety disorders in psychiatrically referred adults with ASD
J O S H I E T A L . , 2 0 1 3
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Substance use disorders in psychiatrically referred adults with ASD
J O S H I E T A L . , 2 0 1 3
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Comorbidity associated with ASD
A U T I S M & D E V E L O P M E N T A L D I S A B I L I T I E S M O N I T O R I N G
N E T W O R K S U R V E I L L A N C E Y E A R 2 0 0 2 ; L E V Y E T A L . ,
2 0 1 0 .
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Targeting psychopharmacologic treatment
Sleep
Disruption
Impulsivity Hyperactivity
Inattention
Tantrums
Language
Impairment
Depression
Repetitive
Behaviors
Social
Communication
Deficits
Anxiety
Aggression
Self-
Injurious
Behavior
ADHD
M C D O U G L E E T A L . , 2 0 1 6
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Selected ASD Level 1 and Level 2 screening tools
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ASD Level 2 interactive screening tests & other useful tools
R I T A - T : R A P I D I N T E R A C T I V E S C R E E N I N G T E S T I N
T O D D L E R S ; S T A T : S C R E E N I N G T O O L F O R A U T I S M I N
T O D D L E R S A N D Y O U N G C H I L D R E N
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The four A’s
A D A P T E D F R O M C O N J O I N T B E H A V I O R A L C O N S U L T A T I O N :
P R O M O T I N G F A M I L Y - S C H O O L C O N N E C T I O N S A N D
I N T E R V E N T I O N S , 2 , E D I T E D B Y S . M . S H E R I D A N & T . R .
K R A T O C H W I L L , 2 0 0 7 N E W Y O R K : S P R I N G E R S C I E N C E A N D
B U S I N E S S M E D I A .
Touchstone
Health Services
8 6 6 . 2 0 7 . 3 8 8 2
T O U C H S T O N E H S . O R G
P H O E N I X M E S A A V O N D A L E T U C S O N
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Evidence-based practices
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Evidence-based practices
• Applied Behavior Analysis (ABA) Therapy
• Characteristics of Early Intensive Behavioral Intervention in ASD
• Early Intensive Behavior Intervention (EIBI)
• Efficacy of Early Intensive Behavioral Intervention (EIBI)
• DIR/Floor Time ®
• TEACCH: Treatment and Education of Autistic and Related Communication – Handicapped Children
• TEACCH” A “Culture of Autism”
• TEACCH: A Meta-Analysis
• TEACCH Method for Social Skills Training
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Evidence-based practices
Wong, C., Odom, S. L., Hume, K. A., Cox, C. W., Fettig, A., Kurcharczyk, S., et al. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-014-2351-z
National Autism Center. (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author.
Mercy Care Plan l Mercy Maricopa
Comparison of NPDC and NSP Practices
NPDC 2017
Evidence-Based Practices Identified by
the National Professional
Development Center (NPDC) on ASD
Established Treatments Identified by the National Standards Project (NSP)
Behavioral Interventions
Cognitive Behavioral
Interventions
Modeling Natural
Teaching
Strategies
Parent Training
Peer Training Package
Pivotal Response
Training
Schedules Scripting Self-
management Social Skills
Package Story-based Intervention
Language Training
Comprehensive Behavioral
Treatment for Young Children
Antecedent-based Intervention
X Language training did not emerge as a focused
intervention by the NPDC on ASD. Components of Language
Training overlap with NPDC identified practices that may support
language production, such as modeling, prompting, and reinforcement.
The NPDC on ASD did not review comprehensive
treatment models. Components of The Comprehensive
Behavioral Treatment of Young Children overlap with many NPDC
identified practices.
Differential Reinforcement
X
Discrete Trial Training X
Extinction X
Modeling X X
Prompting X
Reinforcement X
Response Interruption/Redirection
X
Scripting X X
Task Analysis X
Video Modeling X X
Time Delay X
Cognitive Behavioral Intervention
X
Naturalistic Intervention X
Parent Implemented
Intervention X
Peer-mediated Instruction & Intervention
X
Pivotal Response Training X
Self-management X
Social Narratives X
Social Skills Training X
Visual Supports X
Exercise Exercise was identified as an emerging practice by the NSP.
Functional Behavior Assessment
The NSP did not consider Functional Behavior Assessment as a category of evidence-based practice.
Functional Communication Training
Functional Communication Training was identified as an emerging practice by the NSP.
Picture Exchange Communication System
Picture Exchange Communication System was identified as an emerging practice by the NSP.
Structured Play Groups The NSP did not consider Structured Play Groups as a category of evidence-based practice.
Technology-aided Instruction & Intervention
Technology-aided Instruction and Intervention was identified as an emerging practice by the NSP.
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Mercy Care Plan l Mercy Maricopa 29
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Member-Centered Practices
Primary responsibility of the Care Coordinator
Communication • Continuous between Care Coordinator in
Accessible Language
• Communication between Providers
• Internal Database
• Develop a Process for Communication with Multi-Systemic Partners
• Members and Providers Participate in CFT
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Member-centered practices
Care Coordination
Integrates Community Resources
Engages in Networking
Opportunities
Patient-centered Training
Provides Case Management
Provides Coaching to Families and
Providers
Continuous Patient
Communication
Supports and Facilitates Transitions
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Psychiatry Services
MMWIA: Whatever It Takes
Direct Service Providers
Respite Services
Outside Agencies & Programs
Behavior Analytic Programs:
FCAP
Language & Learning Center
FBAs
Severe & Complex Cases
Intensive Outpatient Programs
Infant Early Childhood Program
ASD Informed Care Coordination
THS Professionals: • Psychiatrists • Psychiatric Family Nurse
Practitioners • Doctor of Osteopathic Medicine
(D0) • Medical Assistants (MA) • Board Certified Behavior Analyst®
(BCBA) • Registered Behavior Technician®
(RBT) • Licensed Associate Counselor (LAC) • Licensed Associate Marriage and
Family Therapist (LAMFT) • Licensed Behavior Analyst (LBA) • Licensed Clinical Social Worker
(LCSW) • Licensed Independent Substance
Abuse Counselor (LISAC) • Licensed Marriage and Family
Therapist (LMFT) • Licensed Master Social Worker
(LMSW) • Licensed Professional Counselor
(LPC)
Coming Soon: Primary health care • Medical assessment • Screening for co- morbidities • EPSDT assessments Employment Diet and nutrition Speech Language Communication
Family & provider engagement
Collaboration
• ACEs can not provide all services
• Need for partnerships • Medical
• Behavioral
• Educational
• Community
Education
Touchstone Health Services ACE Trainer • Direct training for:
Families
Agencies
Stakeholders
• Understanding the system and rights
• Services available in the system
• Evidence-based practices
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THS ACE Trainings: Technical support for the whole community
• Applied Behavior Analysis • Chronic stressors experienced by caregivers and family members of
persons with ASD • Early intervention for children with ASD • Effective discipline practices • Effective teaching practices • Introduction to ASD • Positive behavior supports (PBS) for classrooms and schools • Writing measurable treatment/IEP/CFT/ISP goals and objectives • Nationally recognized best practices outlined in: - National Autism Center. (2015). Findings & conclusions: National standards (phase 2). Randolph,
MA: Author. - Wong, C., Odom, S. L., Hume, K., Cox, A. W., Fettig, A., Kucharczyk, S., … Schultz, T. R. (2013). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group.
Mercy Care Plan l Mercy Maricopa
Meet with
ACE Team
Lead
External
Referrals
Internal THS
Referrals
Treatment
Plan
Work with
Care
Coordinator
& Treatment
Providers
First 7 Days of Care Next 21 Days of Care Continuing Care
Reassess/
Discharge
Language and Learning Center Functional Behavioral Assessment Trauma Informed Care
Gastrointestinal Specialist
4 Years-old
Limited language
New Diagnosis of ASD
Gastrointestinal issues
Recently removed from her home after abuse allegations
Recently started biting her arm, breaking the skin
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Thank you
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